288 e-Letters

  • The Yentl syndrome effect on Idiopathic pulmonary fibrosis

    “The Yentl Syndrome” coined in 1991 by Bernadine Healy is the different course of action that the treating physicians usually follow for women than for men (1,2). The name is taken from the 1983 film Yentl starring Barbra Streisand in which her character plays the role of a male in order to attend school and study the Talmud. Being "just like a man" has historically been a price women have had to pay for equality. Throughout the centuries women, considered different and second-class from men, have too often been treated less than equally in various aspects of life, including education and health care (2). Bernadine Healy (1) pointed out in an editorial for the two studies (3,4) published in the same journal demonstrating that women who are hospitalized for coronary heart disease undergo fewer major diagnostic and therapeutic procedures than men as physicians pursue a less aggressive management approach in women than in men, despite greater cardiac disability in women.
    Later, two studies (5,6) demonstrate under-treatment of women with medication, including lower rates of aspirin and ACE inhibitor use in stable women compared with men, as well lower rates of ACE inhibitor, beta-blocker and statin medication in acute coronary syndrome women compared with men. Both studies also show gender differences in use of procedures, where stable women undergo more repeat angiography, whereas acute coronary syndrome women undergo fewer angiograms, percutaneous coronary in...

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  • Stop respiratory support? - we will take some convincing!

    Langley RJ*1, Pabary R1, Trucco F1, Bush A1.

    Department of Respiratory Paediatrics and Sleep Medicine, Royal Brompton Hospital, London, UK
    *Corresponding author - rosslangley@nhs.net
    No conflicts of interest

    Dear Editor

    Whilst we recognise the need for caution and careful planning when considering the ongoing use of home non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) in children during the COVID-19 pandemic, we read with some concern the recent views by Barker et al.1 recommending the discontinuation of respiratory support unless “medically necessary to support life”.

    There is undoubtedly a risk to caregivers and relatives of potential aerosolisation of infectious material. This is true not just of COVID-19, but also potentially harmful viruses such influenza A, respiratory syncytial virus (RSV) and many other respiratory viral pathogens which commonly infect children. This is not a new threat, but a new virus.

    However, advising withdrawal of CPAP/NIV support, which is always prescribed for sound medical reasons in children, is not just misplaced but potentially dangerous.

    Firstly, there is a real danger in providing such advice at time of crisis when one cannot fully assess or appreciate the impact of withdrawing treatment on “peacetime” health. Children requiring respiratory support often struggle to comply and reduced use over time would undoubte...

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  • British Thoracic Society (BTS) position statement on environmental and lung health

    In a position statement published in March, the British Thoracic Society (BTS) recommended that ‘where a new class of inhaler is commenced, this is a Dry Powder Inhaler (DPI)’. The statement went on to state that ‘ Where patients are using several classes of inhalers and poor inhaler technique is identified with one device, that the DPI class is prioritised if the patient is able to use these safely. Similarly, future and
    additional inhalers would ideally also be DPIs; and that during all respiratory reviews, prescribers
    recommend low carbon alternatives to patients currently using Pressured Metered Dose Inhalers
    (pMDIs), where patients are able to use these safely’.

    We are extremely worried by the potential impact that these recommendations could have, since they come from a trusted body which has the reputation to place the health, needs and safety of patients above all. This statement encourages prescribers to change their prescribing habits, not to patient care and safety, but to the systematic exclusion of metered-dose inhalers in favour of dry powder devices for highly debatable environmental concerns. Since the vast majority of prescribers are not experts of inhalation therapy, such guidance may put some patients in danger and lead to a loss of opportunity to optimize care.

    Metered-dose inhalers are used much more reliably with spacers by young children and those with impaired respiratory function. It is well established (1) that pat...

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  • Response to Kennedy et al

    We thank Dr Kennedy and colleagues for their interest in our recent
    paper comparing outcomes after surgery and SABR radiotherapy in
    stage I non-small cell lung cancer (1,2) .
    We agree that intraoperative nodal upstaging can be a cause of stage
    migration in the surgical arm but not the SABR arm, and so could act
    as a potential bias in an observational study. This might
    overestimate the benefit of surgery compared to SABR. The Society
    for Cardiothoracic Surgery Database Project reported 2155 patients
    undergoing lung cancer resections in England from 2014-16, and
    found that over 13% of patients underwent nodal upstaging when
    their resection pathology was analysed (3) .
    The information bias inherent in having full pathological data
    available for surgical but not SABR cases leads to other potential
    problems with analysis. All patients undergoing surgery have a
    pathological analysis confirming the cancer and its stage, while 240
    of the 476 patients treated with SABR were treated without a
    pathological diagnosis. A recent prospective UK study found that
    14% of patients operated on for presumed lung cancer had benign
    disease on intraoperative frozen section biopsy or final pathology (4) .
    Assuming that this surgical false negative rate approximates the rate
    in the suspected early clinical stage patients treated with SABR, then
    around 7% of our SABR arm may...

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  • Response to Laura W Lund, and Jeremy D Kimmel ALung Technologies January 16, 2020

    The SUPERNOVA trial was a prospective observational phase II study supported by an unrestricted grant from three companies (Alung, Maquet, and Novalung) and by the European Society of Intensive Care Medicine (ESICM). The three companies provided equipment and covered costs for data monitoring, site visits, and insurance fees. The grant (€171,000) was made available to ESICM that supported data collection and analysis, and all administrative costs. As owner of the data, ESICM appointed the two principal investigators (AC and VMR) and the independent Data and Safety Monitoring Board (Jukka Takala, Chair). The study included 95 patients. The proportion of patients who achieved ultra-protective settings by 24 hours was 82%. Number of patients that experienced severe and ECCO2R-related adverse events was 2 (2%) and 37 (39%)1. Retrospective analysis of these data showed that (a) efficacy of ECCO2R to facilitate further reduction of tidal volume was lower with smaller artificial lungs and running at lower blood flow than with larger artificial lungs and running at a higher blood flow2; (b) haemolysis and bleeding was higher with the former than with the latter2; (c) applying these data to a previously described theoretical model3 we predicted that incorporating higher CO2 removal rates as factors to design randomized clinical trial might substantially reduce screening and sample size requirements4.
    In her letter, Dr Lund, expressed several concerns about these findin...

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  • Nodal staging should not be left out of the equation

    We read with interest the report from Khakwani and colleagues comparing real-world outcomes for patients with stage I NSCLC undergoing surgery and stereotactic radiotherapy (SABR) (Ref 1), together with the accompanying editorial (Ref 2). Given the failure to recruit to previous randomised trials designed to compare these treatments, analyses of large national datasets are vital to improve our understanding of how best to manage this patient group.

    One additional possible explanation for the worse outcome in the SABR cohort relates to occult nodal involvement. Inaccuracies in clinical staging are well described; one analysis documented that 34% of patients are under-staged by pre-operative work-up (Ref 3). Patients with occult nodal disease would have been identified in the surgical group by intraoperative systematic nodal staging, and would therefore have been excluded from analysis of the Stage I cohort presented here (Ref 1). Patients who are similarly under-staged prior to SABR treatment will remain in the Stage I cohort for analysis, yet will have worse outcomes by virtue of their more advanced disease. Comparing outcomes on an intention-to-treat basis using pre-treatment stage may minimise this bias.

    We agree with the authors that residual confounding may be an important factor explaining these results, and that examination of cause of death is instructive. In our single centre study, cause of death was compared (on an intention to treat basis) between...

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  • Response to "Efficacy and safety of lower versus higher CO2 extraction devices to allow ultraprotective ventilation: secondary analysis of the SUPERNOVA study" (Combes et al,, 2019 Dec;74(12))

    Dear Editor,

    We read with great interest the recently published article in Thorax by Combes and colleagues titled “Efficacy and safety of lower versus higher CO2 extraction devices to allow ultraprotective ventilation: secondary analysis of the SUPERNOVA study” [1]. In this article, the authors present brief, post-hoc analyses of safety and efficacy data derived from the SUPERNOVA trial, a single-arm, multi-center, pilot study assessing the feasibility and safety of extracorporeal carbon dioxide removal (ECCO2R) to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress syndrome (ARDS) [2]. The study was conducted at 23 centers, each of which used one of three different ECCO2R devices.

    We wish to communicate significant concerns regarding improper categorization of ECCO2R device performance as well as important study limitations impacting interpretation and value of the presented data. The differentiation between devices based on the terms “higher CO2 extraction” and “lower CO2 extraction” is incorrect based on supporting evidence and engineering principles summarized in this letter. In addition, safety data was presented and statistically compared without including available associated data that would bring in to question the implications of the analyses. As the manufacturer of one of the ECCO2R devices used in the SUPERNOVA pilot study, we are strong believers in the life-saving potential of ECCO2R technology and its...

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  • Carbon footprint impact of the choice of inhalers for asthma and COPD. Response to letter from Murnane et al.

    Dear Editor

    We thank Professor Murnane and co-authors for their comments on our paper: “The carbon footprint impact of the choice of inhalers for asthma and COPD” [1]. Unfortunately, there are some misunderstandings in their letter and we are happy to try to resolve them.

    1. Our study was intended to look at a high-level model for carbon savings in respiratory care, using existing device options with recognised limitations for wider application. It is not a blueprint for system change or a fully costed recommendation for health decision makers. We do not think that it is realistic to change the prescribing patterns from the current 70% pMDIs in England to Swedish levels. We do, however, think it is important to illustrate the potential GWP gains that can achieved if the suggestions in the BTS statement on ‘the environment and lung health’ and the sustainability ambitions of NHS England in its Long Term Plan (7) are followed: “Complete elimination of pMDIs may not be possible due to patient preference and the need to generate sufficient inspiratory flow to activate the DPIs. However, BTS encourages all prescribers and patients to consider switching pMDIs to DPIs whenever they are likely to be equally effective.” (5).

    2. The Murnane et al response refers to content which is not in our paper, such as ‘switching pMDIs to the cheapest DPIs’. The paper does not analyse or compare the costs of switching as this is outside the scope of the study. While th...

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  • Reply to 'Patient engagement is vital'

    We thank John White for his letter and wholeheartedly agree that switching of inhalers, for any reason, should solely be done after assessing the suitability of the switch for each individual patient and with full engagement and agreement of the patient. We also thank him for further raising the issue of the environmental impact of inhalers. As he points out, our study found that following a switch of inhalers, there was no deterioration in disease control. It is worth noting that this improvement was found with all switches we assessed, including those switching from MDIs (containing propellants containing potent greenhouse gases) to DPIs (containing low global warming potential). We agree that a potential reason for improved disease control was an interaction between clinician and patient, also explaining the increased adherence. We too have anecdotally come across patients for which switching inhalers for financial reasons appeared to be detrimental to their health; this was the impetus for the study. The study findings were perhaps unexpected, but as epidemiologists, feel this shows the relevance of considering the whole population at risk, and as clinicians, the importance of tailoring interventions to the individual.

  • Carbon footprint, environmental impact, and patient outcomes in inhalation therapy: No simple solution to the complex challenges

    It was with great interest and not a little concern that we read the recent Brief Communication by Janson and colleagues [1] into the impact of pressurised metered dose inhalers (pMDIs) on the global warming potential (GWP) of respiratory care. We note the tenacity of one of the authors who has succeeded in publishing a second paper [2] based on a similar, flawed logic just two weeks later. The sense of proportion that is missing in both reports has, thankfully, been identified in the press this week.[3] However, we feel it essential to scrutinise the current contribution scientifically.

    The authors report the carbon footprints of a range of devices marketed by GlaxoSmithKline (GSK) following analysis undertaken by the Carbon Trust (a UK not-for dividend company). Subsequently, calculations were undertaken aimed to determine how the carbon footprint of inhalation therapy in the UK’s National Health Service (NHS) might be reduced by altering the prescribing patterns of UK physicians (where more pMDIs are prescribed than dry powder inhalers (DPIs)) to resemble those of Swedish physicians (where the converse holds). While we acknowledge the authors’ declaration that their data are potentially flawed by the fact that their calculations are based on extrapolating the carbon footprints of just three device formats manufactured by one company to predict the effects of total DPI and pMDI usage in the UK when the carbon footprints of most other devices are unknown, we wou...

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